Electronic referrals

Sissinghurst, June 2012

We have a new computerised referral system. The old referral system involved the telephone and pieces of paper with words written on them. Nurses on the wards would phone our office, and the admin team would write some scanty and usually misleading details about the referral, on paper forms kept in a file. When each of us had seen a referral intended for us, we would tick the form to show we were dealing with it, and go off and deal with it. This involved the admin team in answering the phone quite a lot, but on the plus side, they would do some basic triage and reject inappropriate referrals or bleep us if they thought we needed to know about a referral straight away.

The new referral system has been added to one of the many hospital systems that exist. The most surprising things about the introduction of this system were a) that we were told on the Friday that it would start on the following Tuesday, and b) we were given no information about how it would work or what we should do to pick up referrals or manage them once we had them. You can imagine that it has been a pretty steep learning curve, both for us and for the nurses on the wards. The main people to benefit have been the admin staff, who no longer have to write anything on the referral forms, but do still have to tell the nurses who continue to call the office that we don't accept telephone referrals any longer.

It has been an interesting experience, working with a new computer system that has not been designed or adapted for our use. I am still ignorant of the purpose of the change - why ditch a paper system that worked perfectly well for a computerised system that seems to work no better? It is possible that some numbers can be extracted more easily from the computer than from reams of paper forms, but which numbers are they, and what do they mean? If numbers were at the bottom of the change, then surely we would be given some instruction on how the system should be used, so that the numbers extracted would mean what they were intended to mean.

As an example, the nurses on a ward complete one section of the online referral form, and we then open the entry and can see what they have written. The referral has three options for status: when it is created it is 'Open', then it can be 'Under Review', where it sits on a viewable list, or 'Closed' when it still exists and can be viewed and edited, but is no longer on the special list, which only shows referrals that are Open or Under Review.

So we can assume that 'Open' means the referral is a new one. The next thing that used to happen was that we would tick the referral form and do a bit of background research before seeing the patient. We might see the patient several times, before they either died, left the hospital, or didn't need our input any more. At which point should we change the status to Under Review, or Closed?

The system has been in use for nearly two weeks, and the consensus about this has shifted several times. The latest informal discussion concluded that ticking the form in the book corresponds to changing the status to Under Review and typing our initials as the first entry. Actually seeing the patient prompts a change to a status of 'Closed', even though we may continue to see the patient many more times. And now, each time we see a patient, we are supposed to write something on the electronic record as well as writing on the record card.

I imagine that someone will gather the numbers about how many of these referrals are made, and perhaps the time between the various changes of status. That 'someone' will have little information about what these numbers or times mean, otherwise they might have specified what they wanted and told us how to operate the system in advance of going live.

The overall effect of this new system, after nearly two weeks of operation, is that the admin staff have considerably less to do now that phone referrals have almost stopped, but there has been an equivalent increase in workload for nurses and doctors who are now making the referrals online, and we Dietitians having to make additional notes where we didn't before. And our head of service is getting some data that she didn't have before.

There is a positive side to this, however. In time, we will be able to see whether a patient has had previous contact with a Dietitian on a ward, which is very useful information that we don't have at present. We might also be able to see details of what was done on that previous occasion without having to track down a physical card that might be archived in a warehouse somewhere. The electronic referrals also have scope for the nurses to provide a good deal more relevant detail about a patient than they used to on the phone.

The negative aspects, apart from those outlined above, also include the fact that access to computers on the wards is very limited - the doctors are usually using them to look up blood results, scans and x-rays and results of investigations. This has made it quite difficult for nurses to actually do the referrals online.

If you have read this far, you either know me personally and imagine that this blog entry will get more interesting by the end, or sufficiently obsessive not to be able to stop reading until you have finished. Or, in the case of Lola II, you will have skipped the majority of the boring bits and reached here to finish off, which is not a criticism of Lola II, but in this case a very sensible way to deal with a fairly tedious text. Well done for getting here! Next time, perhaps there will be something more interesting. Unfortunately, the most interesting bits are about patients, and what makes them interesting is precisely what makes them impossible to write about.

Discharge

Pump Room Gardens, May 2012

Today is Friday, the last of my pointless days off, without which I would have felt cheated, but after which there is always twice as much work to do. So yesterday was my last full day in the week, trying at least to see every patient who hadn't been seen the previous week. Yes, I'm struggling to review longstanding patients once a fortnight now.

While I was thus engaged, every colleague in the hospital was conspiring against me. A patient is going home with a tube feed, and both colleagues in the Dietetics office who help out in this situation were on holiday. Another patient may be going home on a puree diet, and will need information and advice on how to achieve this at home. A doctor has specifically requested a Dietitian to see a patient with interesting blood results as soon as possible. A previously tube-fed patient is now able to eat, so the tube feed has to be adjusted or discontinued. A Ward Manager wanted to talk to me in her office about a specific patient, and I had a lecture to attend at lunchtime and my first clinical supervision after lunch.

Patients leaving my wards are almost as much work as patients who stay there. I am still trying to grasp all the different options and processes that need to be followed. If they are eating and drinking well when they go home I can put their Dietetic Record Card in a plastic basket in the office and relax (this is rare). There is a different basket for 'RIP' cards. If a patient is transferred to a different hospital, we have to contact the dietitians there and let them know what the situation is, especially if the patient is being tube-fed, and sometimes send the Record Card over as well (depending on whether the hospital is in our region or not).

If a patient goes home but is not likely to eat and drink enough, there are a number of options. I can write to the GP asking for supplements to be prescribed for a period of time and leave it up to the GP to review the situation, or send the patient an outpatient appointment with a Dietitian (there is a different basket for the Record Card if this is the case). If the patient is going to a nursing home, I can be fairly confident that their nutritional status will be monitored, but I can pass the Record Card to our Community Dietitian if there are any worries. She also looks after every patient who is sent home with a feeding tube, whether it is being used or not. Even if not used, the tube needs to be looked after, and eventually removed.

If a tube is being used for feeding into the stomach, there are many administrative and practical steps that must be taken before discharge. The patient needs to be sent home with enough supplies to ensure they are fed until further supplies are delivered. This means bags of feed (between 7 and 14 kg altogether), a pump, a stand, tubes to connect the feeding tube and the feed, syringes for flushing the tube with water, and sometimes a water container have to be physically taken to the ward in time for the discharge. There is a form that gives the patient and/or their carers instructions on how much feed to give at what rate over a specific period of time and how much additional water is needed. They need to sign a form to consent to their address details being given to the company that will be delivering the feed. The Dietitian has to register the patient with this company and provide all the same details and more, and then print a letter to the GP asking for the feed prescription to be arranged. Then all this is handed over with the Record Card to the Community Dietitian. Sometimes the ward forgets to mention that someone is due to be discharged on a feed imminently, so everything else has to stop until it is all sorted out.

More difficult is if the patient needs a modified texture diet, especially if they are elderly. Constructing a nutritionally adequate diet when everything has to be blended to a smooth lump-free puree is not straightforward, especially if the patient doesn't have a blender or liquidiser. If fluids also need to be thickened, then the choice of supplements is limited too. Chances are that the patient will lose weight, become dehydrated, and/or eat or drink something that goes down the wrong way and they end up with a chest infection or worse. There is a commercial company that will deliver pureed ready meals, a bit like Meals on Wheels, which can help a great deal, as long as the patient can afford it. It is likely that the patient will be on supplements long-term, and even need to be seen occasionally in outpatients.

There are different baskets for Record Cards of clinic outpatients who are going to come back for a further appointment, outpatients who have been discharged, and outpatients who didn't attend their appointments. There is another basket of Record Cards for upcoming outpatient clinics. There are probably more baskets that I'm not even aware of yet, perhaps for newly referred patients, and for IV feeders at home (Home Parenteral Nutrition).The Dietetic admin staff who manage all these baskets (and much more) are universally helpful, patient and good-natured, and don't seem to mind me asking the same questions multiple times. In fact, all the Dietetic staff seem friendly and supportive (have I mentioned that before? Probably). Tonight we have arranged a departmental outing in a local Indian restaurant, and despite my nervousness about large social groups, I think it will be fun.